Form 1099-K Merchant Card for Third Party Payments

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Page 1 of 6 of Form 1099-K (Page 2 is Blank)

Date

Signature

O.K. to print
T:FP:F

10

The type and rule above prints on all proofs including departmental
reproduction proofs. MUST be removed before printing.

O.K. to print
Responsible
scan organization

Date

Separation 1 for page 1 of Form 1099-K. Prints in
Red (J-6983) Ink.
Separation 2 for page 1 of Form 1099-K. Prints in Black Ink.

Revised proofs
requested

Do not move lines on form.The boxes have different depths
and some don’t fall on the grid. The forms depth is 4.5" from
top rule to bottom rule.

remove this box
remove shading
taxpayer/
1010

VOID

Network/

CORRECTED

FILER’S name, street address, city, state, ZIP code, and telephone no.

FILER’S federal identification no. OMB No. 1545-XXXX

PAYEE’S federal identification no.

2011

Merchant Card
and Third Party
Payments

PSE’S federal identification no.
Form
Check box if FILER is Payment Settlement Entity (PSE)

1099-K

1 Gross amount of merchant 2
card/third party payments

OR
Check box if FILER is Electronic Payment Facilitator (EPF)/
Third Party Payer (TPP)

$

PAYEE’S name

3

Copy A
For
Internal Revenue
Service Center

4

File with Form 1096.
Street address (including apt. no.)

5a

January

$
5c
5e
5g

May

5f
5h

July

5k

1099-K

5j

October

5l

December

$
Department of the Treasury - Internal Revenue Service

Cat. No. 54118B

Do Not Cut or Separate Forms on This Page

August

$
November

$
Form

June

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2011 General
Instructions for
Certain Information
Returns.

$
September

$

Account number (see instructions)

April

$

$
5i

5d

$

$
PSE’S name and telephone number

February

$
March

$
City, state, and ZIP code

5b

—

Do Not Cut or Separate Forms on This Page

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1. Remove PSE'S federal identification no. box.
2. Shorten Year box to 1 inch in height. Move number and
words "Form 1099-K" up to fit in it.
3. Increase height of boxes 1 and 2 to 0.6 inches and
move up to occupy empty space. Box 2 remains shaded.
3. Move shaded boxes 3 and 4 up to fill new empty space.
4. Increase height of boxes 5a through 5l to 0.4 inches
each.

10

Page 3 of 6 of Form 1099-K

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Do not move lines on form.The boxes have different depths
and some don’t fall on the grid. The forms depth is 4.5" from
top rule to bottom rule.

remove this box
taxpayer/

Network/

CORRECTED
FILER’S name, street address, city, state, ZIP code, and telephone no.

FILER’S federal identification no. OMB No. 1545-XXXX

PAYEE’S federal identification no.

2011

Merchant Card
and Third Party
Payments

PSE’S federal identification no.
Form
If checked, FILER is Payment Settlement Entity (PSE)
OR
If checked, FILER is Electronic Payment Facilitator (EPF)/
Third Party Payer (TPP)

$

PAYEE’S name

3

Street address (including apt. no.)

5a

5c

January

5g

May
July

5k

$
Form

1099-K

(Keep for your records)

April

5f

June

5h

August

$
September

$

Account number (see instructions)

5d

$

$
5i

February

$

$
PSE’S name and telephone number

5b

$
March

$
5e

Copy B
For Payee

4

$

City, state, and ZIP code

1099-K

1 Gross amount of merchant 2
card/third party payments

5j

This is important tax
information and is
being furnished to the
Internal Revenue
Service. If you are
required to file a
return, a negligence
penalty or other
sanction may be
imposed on you if
taxable income
results from this
transaction and the
IRS determines that it
has not been
reported.

October

$
November

5l

December

$
Department of the Treasury - Internal Revenue Service

1. Remove PSE'S federal identification no. box.
2. Shorten Year box to 1 inch in height. Move number and
words "Form 1099-K" up to fit in it.
3. Increase height of boxes 1 and 2 to 0.6 inches and
move up to occupy empty space. Box 2 remains shaded.
3. Move shaded boxes 3 and 4 up to fill new empty space.
4. Increase height of boxes 5a through 5l to 0.4 inches
each.

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Page 4 of 6 of Form 1099-K

10

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Instructions for Payee
Merchant card and third party network payers, as
payment settlement entities (PSE), must report the
proceeds of payment card and third party network
transactions made to you on Form 1099-K under
Internal Revenue Code section 6050W. You have
received this form because you have accepted
merchant cards for payments, or because you received
payments through a third party network that exceeded
$20,000 in gross total reportable payment transactions
and the total number of those transactions exceeded
200 for the calendar year.
The PSE may have contracted with an electronic
payment facilitator (EPF) or other third party payer
(TPP) to make payments to you. If you have questions
about the amounts reported on this form, contact the
FILER whose information is shown in the upper left
corner on the front of this form. If you do not recognize
the FILER shown in the upper left corner of the form,

contact the PSE whose name and phone number are
shown in the lower left corner of the form above your
account number.
Account number. May show an account or other
unique number the PSE assigned to distinguish your
account.
Box 1. Shows the aggregate gross amount of
merchant card/third party network payments made to
you through the PSE during the tax year.
Box 5a–5l. Shows the gross amount of merchant
card/third party network payments received by you for
each month of the reporting calendar year. This
amount is provided to assist you in the accurate
preparation of your fiscal year tax return.

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Page 5 of 6 of Form 1099-K

10

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Do not move lines on form.The boxes have different depths
and some don’t fall on the grid. The forms depth is 4.5" from
top rule to bottom rule.

remove this box
taxpayer/
VOID

Network/

CORRECTED

FILER’S name, street address, city, state, ZIP code, and telephone no.

FILER’S federal identification no. OMB No. 1545-XXXX

PAYEE’S federal identification no.

2011

Merchant Card
and Third Party
Payments

PSE’S federal identification no.
Form
Check box if FILER is Payment Settlement Entity (PSE)

1099-K

1 Gross amount of merchant 2
card/third party payments

Copy C

Check box if FILER is Electronic Payment Facilitator (EPF)/
Third Party Payer (TPP)

$

For Filer

PAYEE’S name

3

Street address (including apt. no.)

5a

OR

4

January

$
5c
5e
5g

Account number (see instructions)

July

$
Form

1099-K

5f

June

5h

August

$
September

$
5k

April

$

$
5i

5d

$
May

$
PSE’S name and telephone number

February

$
March

$
City, state, and ZIP code

5b

5j

October

For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2011 General
Instructions for
Certain Information
Returns.

$
November

5l

December

$
Department of the Treasury - Internal Revenue Service

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1
1

1. Remove PSE'S federal identification no. box.
2. Shorten Year box to 1 inch in height. Move number and
words "Form 1099-K" up to fit in it.
3. Increase height of boxes 1 and 2 to 0.6 inches and
move up to occupy empty space. Box 2 remains shaded.
3. Move shaded boxes 3 and 4 up to fill new empty space.
4. Increase height of boxes 5a through 5l to 0.4 inches
each.

Page 6 of 6 of Form 1099-K

10

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Instructions for Payment Settlement
Entity/Third Party Payer
General and specific form instructions are provided as
separate products. The products you should use to
complete Form 1099-K are the 2011 General
Instructions for Certain Information Returns and the
2011 Instructions for Form 1099-K. A chart in the
general instructions gives a quick guide to which form
must be filed to report a particular payment. To order
these instructions and additional forms, visit IRS.gov or
call 1-800-TAX-FORM (1-800-829-3676).
Caution: Because paper forms are scanned during
processing, you cannot file Forms 1096, 1097, 1098,
1099, 3921, 3922, or 5498 that you print from the IRS
website.
Due dates. Furnish Copy B of this form to the
recipient by January 31, 2012.

File Copy A of this form with the IRS by February 28,
2012. If you file electronically, the due date is
April 2, 2012. To file electronically, you must have
software that generates a file according to the
specifications in Pub. 1220, Specifications for Filing
Forms 1097, 1098, 1099, 3921, 3922, 5498, 8935, and
W-2G Electronically. IRS does not provide a fill-in form
option.
Need help? If you have questions about reporting on
Form 1099-K, call the information reporting customer
service site toll free at 1-866-455-7438 or
304-263-8700 (not toll free). For TTY/TDD equipment,
call 304-579-4827 (not toll free). The hours of operation
are Monday through Friday from 8:30 a.m. to 4:30
p.m., Eastern time.

Printed on recycled paper

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